Laparoscopic splenectomy: posterolateral approach in patients with liver cirrhosis and portal hypertension with platelet count lower than 1 × 109/l.

INTRODUCTION: Laparoscopic splenectomy for massive splenomegaly secondary to liver cirrhosis and portal hypertension in patients with an extremely low platelet count (< 1 × 109/l) presents several challenges. The posterolateral laparoscopic splenectomy approach may be a feasible and safe technique for these patients. AIM: To evaluate the feasibility and safety of the posterolateral laparoscopic splenectomy approach in patients with platelet counts < 1 × 109/l secondary to liver cirrhosis and portal hypertension.
MATERIAL AND METHODS: In the period from January 2013 to December 2016, 11 patients with platelet counts < 1 × 109/l secondary to liver cirrhosis and portal hypertension underwent posterolateral laparoscopic splenectomy in our institution. Pre-, peri-, and postoperative medical managements were reviewed retrospectively.
RESULTS: Patients' median platelet count was 0.7 × 109/l at the time of inpatient admission. The median operating time was 75 min, and the median intraoperative blood loss was 30 ml. One patient underwent intraoperative transfusion. The median duration of postoperative hospital stay was 5 days. No intra- or postoperative complications ensued, all patients were followed for 12-32 months (median: 24 months), and none had postoperative complications.
CONCLUSIONS: The posterolateral laparoscopic splenectomy approach is a feasible, safe technique in the treatment of patients with platelet counts < 1 × 109/l secondary to liver cirrhosis and portal hypertension.

Introduction

Laparoscopic splenectomy (LS) was first described by Delaitre and Maignien [1] in 1991 and has become the gold-standard surgical intervention for treating primary hematological diseases, idiopathic thrombocytopenic purpura (ITP), and hypersplenism [2, 3]. The benefits of LS include minimal invasiveness and intraoperative bleeding, less pain, shorter hospital stays, and lower complication rates [4]. Many comparative clinical studies have documented the effectiveness and safety of LS versus laparotomy [5-9].

Low preoperative platelet counts affect the successful use of LS and are associated with higher morbidity, transfusion requirements, and conversion rates [10]. Therefore, a platelet count of at least 30–50 × 109/l is recommended by most surgeons [11]. Wu et al. evaluated severely thrombocytopenic patients with ITP [12]; however, to our knowledge, no studies have discussed the treatment of massive splenomegaly secondary to liver cirrhosis and portal hypertension in patients with severe thrombocytopenia. Therefore, we investigated the feasibility and safety of LS in patients with this condition.

Aim

In this study, we intended to evaluate the feasibility and safety of the posterolateral LS approach in patients with liver cirrhosis and portal hypertension, and platelet counts < 1 × 109/l.

Material and methods

In the period from January 2013 to December 2016, 231 patients admitted to our hospital were diagnosed with splenomegaly secondary to hepatitis B or C liver cirrhosis and portal hypertension. During the same period, 136 patients underwent open splenectomy or LS, while 11 patients with a preoperative platelet count < 1 × 109/l underwent posterolateral LS. Preoperatively, patients underwent a detailed physical examination, abdominal ultrasonography, abdominal computed tomography, and routine biochemical and hematological tests. We retrospectively reviewed patients’ preoperative, perioperative, and postoperative data, and all patients were followed for 12–32 months (median: 24 months). The study protocol was approved by the Institutional Review Board at the People’s Hospital of Zhengzhou University (Henan Provincial People’s Hospital), and all patients gave informed consent in writing prior to surgery.

Surgical technique

Patients were placed in the supine position, and we used the five-trocar placement technique to create access ports. Following the establishment of pneumoperitoneum, a 10-mm port was placed at the umbilicus, and a 30° laparoscope (Olympus Corporation, Tokyo, Japan) was introduced. The pressure ranged from 13 to 15 mmHg. A 5-, 10-, 12-, and 5-mm port was placed below the xiphoid, at the midpoint between the xiphoid and umbilicus, above the transection of the left anterior axillary line and umbilical horizontal line, and at the transection of the left posterior axillary line and umbilical horizontal line, respectively (Figure 1). These positions were adjustable intraoperatively. A monitor was placed on each side of the patient. The surgeon stood on the right side of the patient, and the first assistant stood on the left.

Figure 1

Positions of the trocar ports in laparoscopic splenectomy. A – 10-mm port for the laparoscope, B – 5-mm port for the grasper to expose the splenic hilum, C – 10-mm main manipulation port, D – 12-mm port for the Endo-GIA stapler, E – 5-mm additional manipulation port

The splenogastric ligament was dissected using an ultrasonic scalpel (Olympus), and the splenic artery was identified along the upper margin of the pancreatic body and dissected. Arterial inflow was interrupted by applying a polymer Hem-o-lock clip (Teleflex Inc., Morrisville, NC, USA), and venous outflow was left unhindered to reduce splenic size and minimize blood loss during LS. The splenocolic ligament was dissected, followed by transection of the splenorenal ligament. The splenic pedicle was mobilized along the splenic bed from the lower pole toward the upper pole and from the posterior toward the anterior side of the spleen (Photo 1). The splenodiaphragmatic ligament was then transected. Upon dissection of the splenic pedicle, the primary pedicular vessels were mobilized to a sufficient length using an ultrasonic scalpel, and the primary pedicular vessels were transected and ligated using the Endo-GIA stapling device (blue staples, length: 60 mm, height: 3.5 mm, Covidien/Medtronic, Boulder, CO, USA) (Photo 2). The short gastric vessels were transected and ligated using the Endo-GIA stapler (white staples, length: 60 mm, height: 2.5 mm, Covidien/Medtronic) or polymer Hem-o-lock clips (Teleflex). The spleen was divided into 3 or 4 sections which were enclosed in a specimen bag, morcellated, and removed through the 12-mm port for pathological examination. Patients were prescribed aspirin starting on postoperative day 2 to minimize portal thrombosis.

Photo 1

Dissection and transection of the splenic bed via the posterolateral approach

Photo 2

Transection of the primary pedicular vessels using the Endo-GIA stapler

Statistical analysis

IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis. All categorical data were expressed as frequency with percentage and were compared using Fisher’s exact test. All numerical data were expressed as medians. We performed trend analyses for certain variables using repeated ANOVA measures. Statistical significance was defined as a p-value < 0.05.

Results

Clinical features

The clinical features of the 11 patients are summarized in Table I. The median patient age was 54 years (range: 45–65 years), and 7 (57%) patients were men. On admission, the median platelet count was 0.7 × 109/l. Other (median) parameters were hemoglobin level: 96.0 g/l, white blood cell count: 1.8 × 109/l, prothrombin time: 16.5 s, activated thromboplastin time: 36.3 s, thrombin time: 26.3 s, fibrinogen: 3.9 g/l, and international normalized ratio: 3.0.

Table I

Clinical features of all patients undergoing LS

Parameter	Patient											Median
	1	2	3	4	5	6	7	8	9	10	11
Gender	F	M	M	F	M	F	M	F	M	M	M	–
Age [years]	45	53	64	65	54	49	51	60	57	58	51	54
PLT [× 109/l]	0.8	0.6	0.5	0.9	0.8	0.7	0.4	0.3	0.7	0.3	0.8	0.7
Hgb [g/l]	89	92	101	97	96	84	87	112	108	88	97	96.0
WBC [× 109/l]	2.5	2.0	1.2	1.9	2.0	1.8	1.0	0.9	1.3	1.2	1.8	1.8
PT [s]	15.6	16.3	17.1	16.5	14.9	14.8	17.5	16.7	15.9	17.7	16.8	16.5
APTT [s]	33.9	34.2	35.1	37.8	38.3	37.6	34.5	38.4	36.5	35.8	36.3	36.3
TT [s]	26.7	25.4	26.8	27.2	28.0	25.5	25.9	25.3	25.9	26.3	27.1	26.3
FIB [g/l]	3.9	3.7	3.9	3.9	3.8	4.0	3.8	4.0	3.6	4.0	3.9	3.9
INR	3.0	3.2	3.1	3.0	2.9	2.7	2.9	2.8	2.9	3.5	3.0	3.0

APTT – activated thromboplastin time, F – female, FIB – fibrinogen, Hgb – hemoglobin, INR – international normalized ratio, LS – laparoscopic splenectomy, M – male, PLT – platelet count, PT – prothrombin time, TT – thrombin time, WBC – white blood cell count.

Perioperative details

Patients’ perioperative details are shown in Table II. All patients received fresh-frozen plasma and cryoprecipitate to maintain a target international normalized ratio of 0.8–1.5 and received one unit of platelets 30 min before LS. No patients underwent conversion to laparotomy. Median operating time was 75 min, and median intraoperative blood loss was 30 ml. Patient 6 received an intraoperative transfusion of two units of packed red blood cells combined with 400 ml of fresh-frozen plasma during LS. The median postoperative hospital stay was 5 days. On postoperative day 3 and at the last visit, the median platelet counts were 537.0 × 109/l and 262.0 × 109/l, respectively. All patients received anticoagulant therapies to avoid portal vein thrombosis, and 2 patients (patients 3 and 6) developed portal vein thrombosis.

Table II

Perioperative details for patients undergoing LS

Parameter	Patient											Median
	1	2	3	4	5	6	7	8	9	10	11
Operative time [min]	80	75	80	75	80	95	75	70	80	75	65	75
Blood loss [ml]	20	30	40	30	20	50	30	20	30	20	10	30
PLT transfusion [U]	1	1	1	1	1	1	1	1	1	1	1
Other transfusion	–	–	–	–	–	+	–	–	–	–	–
Conversion	/	/	/	/	/	/	/	/	/	/	/
PHS [days]	5	4	5	5	6	7	4	5	6	5	4	5
3 days after LS
PLT [× 109/l]	513	540	524	533	521	545	538	546	537	522	565	537.0
Last visit [months]	32	29	26	24	23	25	26	22	20	16	12	24
PLT [× 109/l]	268	258	277	254	265	287	251	262	285	254	261	262.0
PVT	–	–	+	–	–	+	–	–	–	–	–

LS – laparoscopic splenectomy, PHS – postoperative hospital stay, PLT – platelet count, PVT – portal vein thrombosis.

Efficacy of laparoscopic splenectomy

Patients’ hematological responses are shown in Table III. On postoperative day 3, the median platelet count increased sharply to 537.0 × 109/l; however, at the last visit, the platelet count was 262.0 × 109/l. Patients’ hemoglobin levels and white blood cell counts also increased. Significant differences were found in changing trends for platelet count, hemoglobin level, and white blood cell count (p < 0.05). We saw a non-significant difference in INR changing trends (p > 0.05), which changed because of the anticoagulant therapies. No differences were found in other coagulation function regarding changing trends (p > 0.05).

Table III

Laboratory examination before and after LS (medians)

Parameter	Inpatient	LS	3 days after LS	Last visit	P-value*
PLT [×109/l]	0.7	0.7	537.0	262.0	< 0.05
Hgb [g/l]	96.0	100.0	109.0	117.0	< 0.05
WBC [×109/l]	1.8	2.3	15.9	4.8	< 0.05
PT [s]	16.5	15.7	15.9	15.7	> 0.05
APTT [s]	36.3	35.0	36.8	36.4	> 0.05
TT [s]	26.3	25.8	26.2	26.0	> 0.05
FIB [g/l]	3.9	3.6	3.8	3.7	> 0.05
INR	3.0	1.2	3.1	3.2	< 0.05

APTT – activated thromboplastin time, FIB – fibrinogen, Hgb – hemoglobin, INR – international normalized ratio, LS – laparoscopic splenectomy, PLT – platelet count, PT – prothrombin time, TT – thrombin time, WBC – white blood cell count.

Repeated measures analysis of variance.

Pathological and follow-up outcomes

Pathological examination revealed congestive splenomegaly in all patients. Patients’ routine hematological test results were normal, and no postoperative bleeding, pancreatic fistula formation, or deaths occurred. By 3 months postoperatively, portal vein thrombosis had occurred in 2 patients (patients 3 and 6), which resolved with administration of 2.5 mg oral coumarin once daily with dose titration to maintain a target international normalized ratio of 2.0–3.0 for 1 year.

Discussion

Laparoscopic splenectomy has become the gold-standard procedure for splenectomy [13] in many centers since its introduction in 1992. The indications for LS are primarily hematological diseases, ITP, splenic hamartoma, and hypersplenism. Refinements in laparoscopic techniques and instruments, and increased clinical experience, have resulted in multiple modifications and refinements in LS [14, 15]. Laparoscopic splenectomy procedures are now safer and more efficient [16]; however, much of the literature supports the role of LS in patients with platelet counts > 30 × 109/l [11]. Other than one study by Wu et al. evaluating LS to treat severely thrombocytopenic patients with ITP [12], there is little information on LS in patients with very low platelet counts secondary to liver cirrhosis and portal hypertension. Poor visualization, enormous spleen size, and the presence of varicose vessels and coagulation disorders, intraoperative hemorrhage, and severe oozing of blood from the cut edge of the spleen are the biggest challenges in LS in patients with extremely low platelet counts [17, 18]. Whether LS is indicated for patients with liver cirrhosis and portal hypertension with platelet counts < 1 × 109/l remains controversial.

The posterolateral LS approach involves dissection and transection of the perisplenic ligaments from the posterolateral face of the spleen, where the adipose tissue is loose and there are no perisplenic varices, reducing the frequency of intraoperative bleeding. As a result, the posterolateral approach provides good visualization of the splenic hilum from the posterior side of the spleen. The low frequency of bleeding reduces the rate of conversion to open surgery and shortens the operative time [19]. After transecting the splenic bed, the spleen can be gently manipulated and suspended, providing good visualization of the splenic hilum. The spleen is also pulled downward by gravity, which stretches the gastrosplenic ligament and expands the operative field [20, 21]. These effects permit forward dissection and transection of the gastrosplenic ligament and short gastric vessels, reducing intraoperative hemorrhage. Our results demonstrate that the posterolateral LS approach provides good surgical outcomes, shortens the LS operation time, and reduces intraoperative blood and oozing. Less intraoperative blood loss also minimizes the requirement for blood transfusion.

Excessive dissection may result in massive bleeding and secondary injury. In the posterolateral approach, there is no need for precise transection of the splenic pedicle and no need to reserve enough space for dissection and transection. This holds true especially in the rear or deep parts of the tissue, where it is easy to miss bleeding or to damage the surrounding tissues because of limited vision or exposure. The posterolateral approach also offers good visualization of the pancreatic tail and facilitates its dissection away from the splenic hilum. This, in turn, provides enough space to transect the splenic hilum with the Endo-GIA stapler [21], reducing the frequency of bleeding and pancreatic fistula. With the Endo-GIA device [22], cutting and stapling are nearly simultaneous, also reducing the risk of bleeding, especially in thick or edematous tissue. As a result, dissection and transection of the splenic pedicle with the stapling device reduces bleeding and minimizes the occurrence of pancreatic tail injury and fistula formation [23, 24]. We dissected the pancreatic tail from the posterior side of the spleen and then transected the primary pedicular vessels with the stapler, reducing the risk of incidental bleeding and shortening the operating time, eliminating the need for excessive dissection, and reducing the risk of pancreatic fistula formation.

Conclusions

The posterolateral LS approach was associated with a good surgical field and no excessive dissection; shortened operation time and hospital stay; and reduced intraoperative blood loss. The posterolateral LS approach is safe and feasible in patients with platelet counts < 1 × 109/l secondary to liver cirrhosis and portal hypertension.

Conflict of interest

The authors declare no conflict of interest.